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May 5th, 2008

Brush with Greatness: Paul Farmer

Perhaps you caught this week’s 60 Minutes, featuring the work done by Partners in Health, the group founded and run by Paul Farmer.

(If he reads this, he’ll no doubt want to correct my description of him as playing these major roles, eager to give equal credit to his impressive colleague Jim Kim and his mentor Howard Hiatt. Ok, done.)

But if you missed the interview, no matter — in all likelihood you’ve heard of him. Maybe you’ve read the fine book about him or seen his smiling face in a variety of newspaper or magazine images. In the Infectious Diseases world, Paul Farmer is a true rock star — our equivalent of Paul McCartney, Mick Jagger, and Bono all rolled up into one guy.

He also was an Infectious Diseases fellow in our program and a clinical attending on our inpatient Infectious Diseases consultation service for several years.

And that’s what I’m going to write about — Paul Farmer here in the resource-rich USA.

You might think it would be difficult for Paul to adapt his clinical practice from rural Haiti to our quaternary-care academic teaching hospital. And you might think, furthermore, that he would have a problem with our spending hundreds of thousands of dollars on ICU care, transplant ID, latest-generation high-tech scans, etc. while the per capita health expenditure for dozens of poor countries is less than $100/year. What a waste.

But you’d be wrong.

Paul was an exceptional Infectious Diseases consultant. He was equally comfortable in all clinical settings: Fortune 500 executives with post-operative fevers after cardiac surgery, marginalized patients with alcohol withdrawal and pancreatitis, and, of course, every stripe of person with HIV or TB. He had no problem communicating with even the most prickly surgical consultants (they loved him), and he quickly endeared himself to patients and their families due to his uncanny ability to treat every sick person like a human being, not a disease.

In short, he was a great doctor.

Is it peevish of me to complain about a few things? OK, but so be it — no human being is perfect, and neither is Paul. So here were the problems:

  1. Everyone loved him, and everyone wanted a piece of him. When Paul would be the attending at our hospital, it was as if Tiger Woods had dropped into a local golf club and offered to give a few quick lessons.  He could barely walk around our hospital without a trail of admirers.  If someone — anyone — said hello to him, he’d remember that person, what they did, who they knew, and what their family was up to — and a lengthy conversation would ensue. Many of our support staff in the hospital are from Haiti; he knew most of them by name. Such activities do not lead to efficient afternoon patient rounds.
  2. Sometimes he promised too much. Once he told a homeless patient he’d get her a new pair of boots before she was discharged. (It was winter.) He then went off service and left for Haiti. No boots. The next attending was left with — literally and figuratively — very difficult shoes to fill.
    (In true Paul fashion, the boots were delivered to her around 6 months later, when he returned.)
  3. Give me a break. He often told me he enjoyed attending here in Boston because it was such a “break.” While no doubt true, he had no idea that this might be a trifle insulting to those of who find inpatient ID attending in the United States pretty darn challenging. And this group includes everyone who’s not Paul Farmer. Once I mentioned this to him, he graciously apologized — and I haven’t heard this since.
  4. Where is he? He called me around 4 years ago with an agonizing dilemma.  Despite enjoying his work as an ID consultant at the Brigham, he was kind of busy with other things (ahem) and would have to stop his 4-6 week stint working with us. So he doesn’t attend here anymore.
  5. I don’t speak Haitian Creole, etc. Periodically someone at the hospital will approach me with a big smile and then start speaking in Haitian Creole. Or a very important person from Harvard Medical School will ask me to be the keynote speaker at a major event, and then — usually just after that warm glow of having made the big time kicks in — they tell me the topic should be “Infections and Inequalities” or “Treatment of HIV and TB in Rural Haiti.” I guess the confusion is understandable: We’re both named Paul (actually “Paul Edward …”), are skinny, balding, wear glasses, and specialize in HIV/ID.  But he’s Paul Farmer, and I’m not.

So those of you looking for cracks in Paul Farmer’s saintly image, sorry, you won’t find it here. I just wish I could get him on our attending schedule for next year.

3 Responses to “Brush with Greatness: Paul Farmer”

  1. Nice piece on Dr farmers. I have read a lot about his works after reading the book about him by Tracy Kiddie, and i continue to be amazed. I hope one day to meet him.

    I believe in using what works, and not in re-inventing the wheel as the popular cliche goes.

    Since, his health model has worked in various settings, why has he not made a case for going global with that model. He works hand-in-hand with the people that make most of the healthcare decisions in the world, the WHO, worldbank, UNICEF, etc etc.

    I have worked in various capacities in the medical sector in Nigeria, and the basic problem is lack of sustainability, inadequate funding,lack of personnel, and a healthcare model that works.

    Since he has it figured out, Is it possible to make his findings and ideas widely available as manual, protocol, or working guide with the personnel and budgetary requirements to make it work.

    I think what he is doing is great, but by doing one country or two countries at a time, he might not live long enough before it gets to the people in my village.

  2. Matthew Powell says:

    Dr. Sax, thanks for an interesting look at one of the “big dogs” of international medicine.

    In partial response to Ndubuisi Edeoga’s question, much of PIH’s work is available for download at http://model.pih.org. Hope that helps.

  3. Matthew Powell says:

    I tried to submit this earlier, so apologies if it posts twice.

    Dr. Sax, thanks for an interesting look at one of the “big dogs” of international medicine.

    In partial response to Ndubuisi Edeoga’s thoughts, much of PIH’s work is available online at model.pih.org … Hope that helps!

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HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Editor-in-Chief

NEJM Journal Watch HIV/Aids Clinical Care

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